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Sudden death in sports

The death of five athletes in one week stirred debate around a problem that affects the world of sports: Sudden Death Syndrome

(24 September 2007) - IT was a typical August night when thousands of spectators in the Ramón Sánchez Pizjuán Stadium in Seville, Spain, along with millions of viewers across the country, fell silent when they saw soccer player Antonio Puerta collapse on the field.

In the middle of panic, their breaths came back when Sevilla midfielder Puerta was able to walk off the field, before being taken to an intensive care unit from the dressing rooms, where he again collapsed. In the way, in one place after the other, he suffered five respiratory arrests.

Few people believed then that this would be the beginning of such a dark week for the world of sports. Puerta struggled for his life for two days, but in the end he lost the most important match of all.

While the image of the Spanish soccer player travelled around the world in tributes and dedications, 27 year-old Zambian forward Chaswe Nsoftwa - who played for the Hapoel Beer Sheva club - collapsed during a training session in an Israeli city. He could not be resuscitated.

On the other side of the Atlantic, 21 year-old Ecuadorian Jairo Andrés Nazareno died from cardiac arrest after a third-category match in his country. A short while later, 31 year-old Ángel Arenales lost his life from cardiac-respiratory arrest after a friendly match with the Atlético Sobrarbe team of veterans, in Huesca, Spain.

Hundreds of kilometres away, 25 year-old French volleyball player Cédric Schilenger suffered from heart failure during a training session with his Chaumont team mates and could not make it to the hospital. It proved that the Grim Reaper was not only interested in soccer players, and that Sudden Death in Sports is a serious problem.

When the heart protests

Even though the contribution of sports to health is undeniable, the spell of bad luck during the last week of summer has stirred debate among the public, always eager for explanations.

German Wilfried Kindermann, head doctor at the 2006 FIFA World Cup, says the closeness among these fatal events was just a coincidence, and that they are more frequent and alarming in soccer because it is the most practiced and advertised sport in the world, and one of the most physically demanding.

The phenomenon of Sudden Death Syndrome (SDS) in Sports is nothing new. It has been scientifically described as the unexpected, non-violent and non-traumatic death that occurs in temporal coincidence with the practice of sports, when less than an hour passes between the beginning of the symptoms and their outcome.

The first known case of SDS in Sports was that of Greek soldier Pheidippides, who died in 490 B.C.E., after running more than 42 km between the cities of Marathon and Athens to announce a victory.

More recent in history includes the images of Cameroon midfielder Marc Vivien Foe, who collapsed during a 2003 Confederations Cup match; those of 24 year-old Hungarian Mirlos Feher, who died in a Portuguese League match at the beginning of 2004; or those, which came months later, accompanying the news that Brazilian Serginho died at age 30 while playing in a match during the main tournament of Rio de Janeiro.

All the cases confirm a studied carried out by the US National Center for Catastrophic Sports Injury, which identified nearly a hundred possible causes of SDS among athletes younger than 35. The great majority were related to the heart.

According to experts, the most frequent triggers include congenital cardiovascular structural abnormalities, such as the arrhythmogenic microvascular abnormality, or the ventricle hypertrophy, heart disease characterized by the thickening of the myocardium muscle of the ventricle, and which seemed to have killed Sevilla's Antonio Puerta.

However, the majority of specialists alert on the effect of the use of doping substances in the vital muscle.

This practice, spread among modern sports, took its first toll during the 1965 French Tour, when British cyclist Tom Simpson suddenly died from a cardiac arrest caused by anabolic steroids taken hours before the race.

Methods like the use of EPO (synthetic erythropoietin), which has become popular in cycling in the last decade, can cause an increase of viscosity in the blood of sportspeople, and increase the risk of deadly thrombosis.

Another analysis comes across with the phenomenon of doping and focuses on the high demands currently ruling professional sports. Nowadays, a level-one soccer player must play around a hundred games per season to fulfil his contract with his clubs, in addition to his duties with national teams. Cyclists must be ready to participate in exhausting races that can almost be classified as superhuman.

In recent declarations to the BBC, Dr.Marcos Antonio Flores, director of the Mexican Institute of Sports Medicine, described this tendency as a serious problem for sports and called it a consequence of excessive commercialization. "In their eagerness to have champions, the clubs put an excessive workload on their players, but they don't have enough ability to adapt, which may be provoking risks of cardiovascular problems," Flores pointed out

Has the alarm sounded on time?

If we look at the SDS phenomenon from the statistical point of view, its incidence could even be regarded as insignificant. Although systematic and quantified studies are scarce, some estimate that there are five cases a year in the United States, out of a million of professional and amateur sportspeople.

Spanish researchers established the incidence at 11 cases a year, in a country where millions of people frequently play demanding sports such as soccer or cycling.

Although it is true that the frequency of these events represents a very small percentage of the number of sportspeople, it is also true that this really small number represents an avoidable tragedy. In most of the cases, the first symptom of SDS is death itself. Puerta, Vivien Foe and Feher were born with a heart condition and they may have never known it. The world learned only after the autopsy that Serginho lived and played soccer to the top of his level with a poor heart and half the normal weight. However, those who pay for his feints and goals had the chance to save him, at least in practice.

All the experts consulted in the wake of these deadly events think that most of the heart conditions suffered by sportspeople can be detected on time through medical exams that go beyond a questionnaire and a general check-up.

The International Federation of Soccer Association (FIFA) is aware of this and demand thorough exams of the heart and blood circulation, including electrocardiograms and ultrasound scans, of all the players on the 32 teams that took part in the World Cup in Germany 2006. This was part of research that was coincidentally made public in late August.

But when the problem is at the level of clubs, reality is very different. Why?

The answer of Chilean cardiologist Paul Mac-Nab, who was consulted about this issue, could be close to the truth. "Sports clubs carry out their general check-ups, focused on performance, and most of the times these are insufficient to detect serious heart conditions. It would take heart screening for each sportsperson, and that would be a more expensive exam. Then, the club owners will wonder if there is a reason to examine all soccer players, or if the cost-benefit relation deserves it. The possible rate of one positive per 200,000 tests aims at taking it as an expense rather than as an investment," said Mac-Nab.

It will never be known if these athletes who died at the peak of their careers, knew about their conditions and underestimated the danger in their search for glory, stardom, the fulfilment of a dream or to maintain profitable contracts. There have been cases of athletes in some countries who know about their condition but refuse to give up sports.

"It represents a high risk to put an athlete under this kind of pressure. In those countries, the responsibility is discharge with the written consent of the athlete. Our health system is different; it feels a higher degree of responsibility towards the athlete. The life and safety of the patient are more important than any medal," said Dr. Frank Dorticos to Bohemia magazine. Dorticos was in charge of the most relevant and recent case of diagnosis of heart condition of a high performance Cuban athlete: the case of swimmer Imaday Núñez.

The young swimmer was diagnosed with Long QT Syndrome after a thorough study. This condition is characterized by an alteration in the conduction system of the heart, which causes arrhythmia and can lead to sudden death.

Fortunately, though with great sadness, Imaday understood giving up swimming was not the end of the world, and that untimely her goodbye to sports would be clearly better than sudden death.


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